Garg PP et al. N Engl J Med 1999;341 (22):1653-60.
Background: At the time of this study, over 200,000 patients in the United States with end-stage renal disease were undergoing dialysis, mostly (2/3) at for-profit centers. Various economic pressures, such as declining inflation-adjusted Medicare payments for dialysis and loss of dialysis center revenue if dialysis patients were instead referred for transplant consideration, prompted this study to determine if quality of care was compromised in for-profit centers.
Objective: To determine whether for-profit facilities responded differently than not-for-profit facilities to financial pressures. Specifically, this research studied the effect of for-profit ownership of dialysis facilities on patients’ survival and rate of referral for transplantation.
Methods: Using data from the U.S. Renal Data System, a nationally representative cohort of patients with end-stage renal disease of recent onset was followed longitudinally for a minimum of 3 years to a maximum of six years, with data collection ending either upon death, or placement on the waiting list for a renal transplant, or loss to follow-up, or the completion of the study period on May 31, 1996. Patients were treated in free-standing for-profit and not-for-profit dialysis facilities. Patients were matched , adjusting for the effects of 14 clinical factors, and for the effects of socio-demographic factors that influence survival and access to transplant lists.
Results: Over 3000 eligible patients were included in either the mortality analysis, the waiting list analysis, or both. The crude mortality rate per 100 person-years of end-stage renal disease was 21.2 for patients treated in for-profit facilities and 17.1 for patients treated in not-for-profit centers (adjusted relative hazard of 1.20; 95% CI between 1.02 and 1.42). The likelihood of being placed on the waiting list for a renal transplant was 26% lower for patients treated at for-profit centers (adjusted relative hazard of 0.74; 95% CI between 0.56 and 0.98). Results were consistent in unadjusted analyses and in numerous multivariate models in which alternative categorizations of key variables were used.
Limitations: The categorization of facilities according to ownership status oversimplified the complexities of organizational structures. Also, the actual date of referral for a transplant by the dialysis facility for evaluation was not given. Instead, date of placement on the waiting list was used as a proxy, though this was unlikely to have biased the results.
Conclusion: For-profit ownership of dialysis facilities, as compared with not-for-profit ownership, is associated with increased mortality and decreased rates of placement on the renal transplant waiting list. Possible explanations for this phenomenon include greater emphasis on income generation at for-profit facilities, arousing concerns that for-profit facilities are more focused on controlling costs and maintaining patient volume than on maximizing positive clinical outcomes. Greater oversight and regulation, albeit costly, may be necessary to ensure that cost containment in investor-owned for-profit facilities is not so extensive that it adversely affects patient outcomes.
Relevance: As parts of Canada explore increasing health care delivery through private facilities, this study warns that we should be concerned with how financial pressures may influence the health outcomes of patients served in for-profit facilities now and in the future.